NCC223482_FRO Submitted_20221012

FINANCIAL RESPONSIBILITY/OWNERSHIP r-ORM
SEDIMENTATION POLLUTION CONTROL ACT L)
No person may initiate any land -disturbing activity on one or more acres as covered by pv�
and an acceptable erosion and sedimentation control plan have been completed and ��
Quality Section, N.C. Department of Environmental Quality. Submit the completed t
Regional Office. (Please type or print and, if the question is not applicable or the e•
number is unavailable, place NIA in the blank.)
Part A.
1. Project Name Waterfront Club, Lot 228 CALDW-2023-025
2. Location of land -disturbing activity: Count Caldwell City or TownshipGranite Falls
Highway/Street 1766 Scenic Lane Latitude(decimai degrees) 35.779877 Longitude decimal degrees} 81.55489
3. Approximate date land -disturbing activity will commence: 9/1 /2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): •75
6. Amount of fee enclosed: $100 . The application fee of $100.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: 8.10-acre application fee is $900).
Checks should be addressed to NCDEQ.
7. Has an erosion and sediment control plan been filed? Yes ❑ Enclosed © No ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Robert Anderson [e-mail]
Name E-mail Address
828-292-1466
Phone: Office # Mobile #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Jeffrey and Ginger Hall
Name
1862 Thoreau CT
Phone: Offce #
� C' P, .-
Mobile #
Current Mailing Address Current Street Address
Connelly Springs NC 28612
City State Zip City State Zip
10. Deed Book No. 2003 Page No 1346 Provide a copy of the most current deed.
DECEIVED
SFP 2 9 2022
LAND QUALITY SECT101'
ASHP1I11 I P

Part B.
1. Company(ies) who are financially responsible for the land -disturbing activity (Provide a comprehensive list
of all responsible parties on accompanied page,) If the company is a sole proprietorship or if the landowner(s) is
an individual(s), the name(s) of the owner(s) may be listed as the financially responsible party(ies).
Jeffrey and Ginger Hall
Company Name
1 862 Thoreau CT
061r) S:�� L 1'1 c._ [ ' a
E-mail Address
Current Mailing Address Current Street Address
Connelly Springs NC 28612
City State Zip
Phone: Office #
City State Zip
Mobile # 132-8 1 / --� & ej —_ S­0 a i
Note: If the Financially Responsible Party is not the owner of the land to be disturbed, include with this form
the landowner's signed and dated written consent for the applicant to submit a draft erosion and sedimentation
control plan and to conduct the anticipated land disturbing activity.
2. (a) If the Financially Responsible Party is a domestic company registered on the NC Secretary of State
business registry, give name and street address of the Registered Agent:
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office # Mobile #
Name of Individual to Contact (if Registered Agent is a company)
(b) If the Financially Responsible Party is not a resident of North Carolina, give name and street address
of the designated North Carolina agent who is registered on the NC Secretary of State business registry:
Name of Registered Agent
Current Mailing Address
RECEIVED
E-mail Address
Current Street Address MND QUALITY SECTION
4SHI=1I11_I. P
City State Zip City State Zip
Phone: Office # Mobile #
Name of Individual to Contact (if Registered Agent is a company)

(c) If the Financially Responsible Party is engaging in business under an assumed name, give name under
which the company is Doing Business As. If the Financially Responsible Party is an individual, General
Partnership, or other company not registered and doing business under an assumed name, attach a copy
of the Certificate of Assumed Name.
Company DBA Name
The above information is true and correct to the best of my knowledge and belief and was provided
by me under oath. (This form must be signed by the Financially Responsible Person if an individual(s)
or his attorney -in -fact, or if not an individual, by an officer, director, partner, or registered agent with
the authority to execute instruments for the Financially Responsible Party). I agree to provide
corrected information should there be any change in the information provided herein.
Ginger Hall Owner
T or pri t name
Si nature
Title or Authority
9/21/2022
Date
I, AmArelt mlt�e lei AVIACa6n , a Notary Public of the County of La d W'el f
State of North Carolina, hereby certify that &I nq& � (0I appeared personally
before me this day and being duly sworn acknowlecYged that the above form was executed by him/her.
Witness my hand and notarial seal, this X1
' Andrea Michelle Anderson
NOTARY PUBLIC
�-� Caldwell County, NC
My Commission Expires August 05, 2026
day of _S�:fc-m ber , 20 d--)'-
0 1
Notary
My commission expires Ak us
RECEIVED
SEP 2 2 2022
LAND QUALITY SECTION'
ASHF1111.1 F,